The comparative effects of metabolic surgery, SGLT2i, or GLP-1RA in patients with obesity and type 2 diabetes: a retrospective cohort study

New antidiabetic agents (sodium-glucose cotransporter-2 inhibitor [SGLT2i] and glucagon-like peptide-1 receptor agonist [GLP-1RA]) and metabolic surgery have protective effects on metabolic syndromes. To compare the changes of metabolic parameters and costs among patients with obesity and type 2 diabetes undergoing metabolic surgery and initiating new antidiabetic agents over 12 months. Hong Kong Hospital Authority database from 2006–2017. This is a population-wide retrospective cohort study consisting of 2616 patients (1810 SGLT2i, 528 GLP-1RA, 278 metabolic surgery). Inverse probability treatment weighting of propensity score was applied to balance baseline covariates of patients with obesity and type 2 diabetes who underwent metabolic surgery, or initiated SGLT2i or GLP-1RA. Metabolic parameters and direct medical costs were measured and compared from baseline to 12 months in metabolic surgery, SGLT2i, and GLP-1RA groups. Patients in all 3 groups had improved metabolic parameters over a 12-month period. Patients with metabolic surgery achieved significantly better outcomes in BMI (−5.39, −.56, −.40 kg/m2, P < .001), % total weight loss (15.16%, 1.34%, 1.63%, P < .001), systolic (−2.21, −.59, 1.28 mm Hg, P < .001) and diastolic (−1.16, .50, −.13 mm Hg, P < .001) blood pressure, HbA1c (−1.80%, −.77%, −.80%, P < .001), triglycerides (−.64, −.11, −.09 mmol/L, P < .001), and estimated glomerular filtration rate (3.08, −1.37, −.41 mL/min/1.73m2, P < .001) after 12 months compared with patients with SGLT2i and GLP1-RA. Although the metabolic surgery group incurred the greatest direct medical costs (US$33,551, US$10,945, US$10,627, P < .001), largely due to the surgery itself and related hospitalization, the total monthly direct medical expenditure of metabolic surgery group became lower than that of SGLT2i and GLP-1RA groups at 7 months. Beneficial weight loss and metabolic outcomes at 12 months were observed in all 3 groups, among which the metabolic surgery group showed the most remarkable effects but incurred the greatest medical costs. However, studies with a longer follow-up period are warranted to show long-term outcomes. 1.Beneficial weight loss and metabolic outcomes at 12-month were observed in metabolic surgery, GLP-1RA, and SGLT2i groups.2.Metabolic surgery had the most remarkable effects on clinical outcomes but incurred the greatest 1-year medical costs, mainly due to surgery and related hospitalization.3.Despite greater medical expenditures, meta